Information Collection

Petition for the Addition of a New WTC-Related Health Condition for Coverage under the World Trade Center (WTC) Health Program

IC 200945 under ICR 201201-0920-011 · OMB 0920-0929.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0929 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Petition for the Addition of a New WTC-Related Health Condition for Coverage under the World Trade Center (WTC) Health Program	Form and Instruction
1 Petition for the Addition of a New WTC-Related Health Co Attachment C_Petition for the Addition of a New WTC-Related Health Condition.pdf	Form and Instruction

IC Title:

Petition for the Addition of a New WTC-Related Health Condition for Coverage under the World Trade Center (WTC) Health Program

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Petition for the Addition of a New WTC-Related Health Condition for Coverage under the World Trade Center (WTC) Health Program	Attachment C_Petition for the Addition of a New WTC-Related Health Condition.pdf		Yes	No	Paper Only

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 100

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 66 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	100	100
Annual IC Time Burden (Hours)	4,000	4,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.